Product complaint form

Practice/dental care provider/lab information

Customer number

Name*

Street address*

Zip code*

City*

Country*

Contacts*

Telephone number*

Email*

System*

Zeramex XT Zeramex P6 Zeramex T-Lock Zeramex P Zeramex T

Zeramex

Item name*

Item number*

Batch number*

By-product, if any

Date of incident*

Type*

Description*

Position*

Product enclosed

Other annexes

Product will be sent subsequently because

Product will not be sent because

Requested replacement

Upload files / photos (max. 5)

Date*

The product was used in accordance with the instructions for use (IFU).

I have read and accept the Zeramex® warranty conditions.

I sterilised the products in question (cleaning is not necessary) and marked the protective bag as STERILE.

I have enclosed the rejected product(s) and X-ray images with this form.

I have read the Privacy Policy and accept it.